Diagnosis and its Discontents: The DSM Debate Continues

“As to diseases, make a habit of two things—to help, or at least to do no harm.”–Hippocrates, Epidemics, in Hippocrates, trans. W. H. S. Jones (1923), Vol. I, 165 [italics added]“An agnostic is someone who doesn’t know, and di- is a Greek prefix meaning “two.” So “diagnostic” means someone who doesn’t know twice as much as an agnostic doesn’t know.”–Walt Kelly, Pogo

A funny thing happened to me on the way to the New York Times “Sunday Dialogue”—I made myself unclear.1 This is not supposed to happen to careful writers, or to those of us who flatter ourselves with that honorific. So what went wrong?

In brief, I greatly underestimated the public’s strong identification of psychiatric diagnosis with the categorical approach of the recent DSMs. But whereas my letter to the Times was indeed occasioned by DSM-5’s release in May, my argument in defense of psychiatric diagnosis was not a testimonial in favor of any one type of diagnostic scheme—categorical, dimensional, prototypical2 or otherwise. (I hope the present essay will save “The Committee to Boycott DSM-5” some time!). Each of these diagnostic schemes has its advantages and disadvantages. My personal preference is for a prototype-based schema, for everyday clinical use; and a DSM-type categorical schema for purposes of psychiatric research.2 The categorical approach is usually preferable for most research studies, because it provides precise “cut-points” for entry criteria. But we should not suppose that our diagnostic categories necessarily “carve Nature at its joints,” in Plato’s famous phrase. Indeed, as philosopher Alexander Bird quipped, “The classifications of botanists do not carve nature at its joints any more than the classifications of cooks.”3 DSM-IV itself understood this, and explicitly recognized its own limitations. In the often-ignored introduction, DSM-IV stated:

Making a DSM-IV diagnosis is only the first step in a comprehensive evaluation. To formulate an adequate treatment plan, the clinician will invariably require considerable additional information about the person being evaluated beyond that required to make a DSM-IV diagnosis.4(pxxv)

And—while I have not seen the text—I expect that DSM-5 will be similarly cautious. I would add to this cautionary note the need for more than a symptom-based approach to diagnosis. In order to gain a full and deep understanding of the patient, psychiatrists must also delve into the patient’s “world view”—her way of “being in the world.” The phenomenologists therefore focus on the structure and contents of the patient’s conscious experience.5,6 For example, does he or she invariably experience the world as a hostile and threatening place? Are all her relationships perceived as threats to her autonomy? And how do the patient’s spiritual concerns and beliefs shape his world-view?7 From the psychodynamic perspective, as Dr James Knoll observes, what are the wishes, fantasies, experiences, fears, and desires that shape the patient’s conscious and unconscious life? (written communication, March 26, 2013). Such depth-psychology is unlikely to be captured in either a categorical or a dimensional “diagnosis” of the patient. Deeper understanding demands that we enter into the patient’s way of “being in the world.”

Physicians, of course, have been reaching diagnostic conclusions since the time of Hippocrates—quite without the help of diagnostic manuals. The word “diagnostic”—notwithstanding Walt Kelly’s sardonic jab—may be understood as “knowing (gnosis) the difference between (dia-)” one condition and another. So, when we recognize that a patient’s auditory hallucinations are related to complex partial seizures and not a psychosis, we are engaging in diagnosis.

A diagnosis, however, need not name a “disorder” or disease. Our diagnosis of Mr. Smith may be, “Perfectly happy chap—nothing to treat here!” Sometimes, in my consultative practice, a patient would ask me for my diagnosis, and I might reply, “Well, I think you have a serious problem with regulation of your mood and your anger. I can give you a formal name for your condition, but I’d rather hear what kind of information you would find most helpful.” That, too, is a “diagnosis”—though not necessarily the “CPT code” an insurance company would accept.

Kudos and brickbatsReaction to my letter was decidedly mixed. While most colleagues were very supportive, many comments in the blogosphere ranged from the dismissive to the abusive. Predictably, some critics trotted out the old war horses of anti-psychiatry (were these not led out to pasture decades ago?): psychiatry is not “scientific,” because it doesn’t have verifiable laboratory tests or biomarkers for its disorders; psychiatric diagnoses are just the “subjective impressions” of the clinician; psychiatry amounts to “totalitarian oppression,” etc.

These canards and slurs have been addressed in many other contexts,8(pp327-353)-10 and I won’t belabor their fallacious assumptions here. Yet psychiatrists should not underestimate the deep currents of public anger and resentment toward our profession, and we must acknowledge that sometimes we have not served our patients well. Psychiatric diagnosis—like diagnosis in other fields of medicine—is sometimes premature. Psychiatric treatments—like many treatments in general medicine—are sometimes ineffective or injurious, despite our best intentions. Patients who have been hospitalized against their will—even when justified on the basis of imminent “dangerousness” and ordered through due process of law—may still have bitter memories of that experience. I truly believe that psychiatry is a force for genuine good—and sometimes quite literally a lifesaver11—but I am also aware of the many challenges we face in building trust with the general public.

The public’s misconception of “science”One thing was abundantly clear from responses to my letter: the general public still does not understand that “science” is fundamentally a habit of mind and method—not a microbe in a dish, or a shadow on a CT scan. Recently, the British Science Council spent a full year developing a definition of “science.” Their conclusion was radically insightful: “Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence.”12 Specifically, science entails careful and systematic observation; hypothesis-formation; and repeated testing of one’s hypothesis, using empirical methods. In this sense, there is no question that psychiatry and psychology are sciences—though they are also more than that.

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